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APPLICATION FOR PERMIT <br /> SAN JOAQUINALOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 42091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> or No. 1862 far welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. -. <br /> -^ ,s City flr' Lot Size PM <br /> Job Address �r <br /> Phone <br /> Owner's Name. <br /> Address <br /> 5 <br /> Contract. Address License No.w_—t.�`__—Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT ❑ _DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O <br /> DISTANCE TO NEAREST: StPT1C TANK SEWER LINES DISPOSAL FLD. PE1>W. VE <br /> FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS ,. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT! CIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca . . ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications <br /> 1-1 public F1 Other Delta _ Depth of Grout Seal Type of Grout <br /> I I irrigation ox. Depth l I Eastern Surface Seal Installed by i <br /> Repair Work Done ype of Pump H.PState Work Done <br /> .- <br /> Well Destr ❑ Weil Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION I (Nos Attic systhin m permitted if public sewer isavaila <br /> eet.I <br /> Installation will serve: ..Residence_ Commercial— Other <br /> Number of living units: . Number of bedrooms �II <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. L1 _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> } r <br /> r _ <br /> LEACHING LINE ❑ No, & Length of lines Total length/size <br /> FILTER BED El Distance to nearest. Well Foundation Property Line <br /> t <br /> SEEPAGE PITS t 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ " <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the,work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California. Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X r Title: Date: <br /> FOR DEPART NT USE ONLY <br /> ~ y ry Date r Area <br /> Applicat on Accepted by <br /> Date�_—��. Final inspection by Date <br /> Pit or Grout Inspection <br /> 7 <br /> Additional Comments; '` <br /> ❑ Stk 466-6781 L] Lodi 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO } <br /> + EH 13+24{REV.1/H 5) <br /> 3c 00 3 00 t �� <br /> EH 14-2e - .JJ <br />